Interaction of Iron Deficiency Anemia and Hemoglobinopathies Among College Students and Pregnant Women: A Multi Center Evaluation in India

Iron Deficiency Anemia: Efficacy and Limitations of Nutritional and Comprehensive Mitigation Strategies

Iron deficiency anemia (IDA) has reached epidemic proportions in developing countries and has become a major global public health problem, affecting mainly 0–5-year-old children and young women of childbearing age, especially during pregnancy. Iron deficiency can lead to life-threatening loss of red blood cells, muscle function, and energy production. Therefore, the pathogenic features associated with IDA are weakness and impaired growth, motor, and cognitive performance. IDA affects the well-being of the young generation and the economic advancement of developing countries, such as India. The imbalance between iron intake/absorption/storage and iron utilization/loss culminates into IDA. However, numerous strategic programs aimed to increase iron intake have shown that improvement of iron intake alone has not been sufficient to mitigate IDA. Emerging critical risk factors for IDA include a composition of cultural diets, infections, genetics, inflammatory conditions, metabolic diseases, dysbiosis, and socioeconomic parameters. In this review, we discuss numerous IDA mitigation programs in India and their limitations. The new multifactorial mechanism of IDA pathogenesis opens perspectives for the improvement of mitigation programs and relief of IDA in India and worldwide.

Significance of borderline HbA2 levels in β thalassemia carrier screening

Increased HbA₂ levels are the characteristic feature of β-thalassemia carriers. A subset of carriers however do not show HbA₂ levels in the typical carrier range (≥ 4.0%) but show borderline HbA₂ levels. As a result, these carriers escape diagnosis and carry the risk of having β-thalassemia major offspring. Borderline HbA₂ values may occur as a consequence of mild β-thalassemia mutations, co-inherited β-thalassemia and α- or δ- thalassemia or iron deficiency anemia. However, there is insufficient knowledge regarding the cause of borderline HbA₂ levels in specific populations. This study aimed to identify the determinants of borderline HbA₂ levels (which we have considered as HbA₂ 3.0–3.9%) in 205 individuals. Primary screening involved detecting the presence of iron deficiency anemia followed by molecular analysis of α, β and δ globin genes. Remarkably, 168 of 205 individuals were positive for a defect. 87% (149/168) of positive individuals were heterozygous for β thalassemia with (59/149) or without (90/149) the presence of co-existing IDA, α or δ gene defects. Notably, 20 of 149 β thalassemia carriers showed HbA₂ < 3.5% and MCV > 80fL. 7 of these 20 carriers were married to carriers of hemoglobinopathies. Our findings describe the genetic basis of borderline HbA₂ levels and emphasize the necessity of a molecular diagnosis in these individuals in the routine clinical setting.

Anaemia and iron deficiency in pregnancy and adverse perinatal outcomes in Southern India

BACKGROUND/OBJECTIVES

We examined the prevalence of anaemia, iron deficiency, and inflammation during pregnancy and their associations with adverse pregnancy and infant outcomes in India.

SUBJECTS/METHODS

Three hundred and sixty-six women participating in a randomised trial of vitamin B₁₂ supplementation were monitored to assess haemoglobin (Hb), serum ferritin (SF), hepcidin, C-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP) during pregnancy. Women received vitamin B₁₂ supplementation (50 µg per day) or placebo daily; all women received daily prenatal iron-folic acid supplementation. Binomial and linear regression models were used to examine the associations of maternal iron biomarkers with pregnancy and infant outcomes.

RESULTS

Thirty percent of women were anaemic (Hb < 11.0 g/dl), 48% were iron deficient (SF < 15.0 µg/l), and 23% had iron deficiency anaemia at their first prenatal visit. The prevalence of inflammation (CRP > 5.0 mg/l: 17%; AGP > 1.0 g/l: 11%) and anaemia of inflammation (Hb < 11.0 g/dl, SF > 15.0 µg/l, plus CRP > 5.0 mg/l or AGP > 1.0 g/l: 2%) were low. Infants born to anaemic women had a twofold higher risk of low birth weight (<2500 g; risk ratio [RR]: 2.15, 95%CI: 1.20-3.84, p = 0.01), preterm delivery (RR: 2.67 (1.43-5.00); p = 0.002), underweight (WAZ < -2; RR: 2.20, 95%CI: 1.16-4.15, p = 0.02), and lower MUAC (β(SE): -0.94 (0.45)cm, p = 0.03). Similarly, maternal Hb concentrations predicted higher infant birth weight (p = 0.02) and greater gestational age at delivery (β(SE): 0.28 (0.08) weeks, p = 0.001), lower risk of preterm delivery (<37 weeks; RR: 0.76, 95%CI: 0.66-86, p < 0.0001); and higher infant MUAC (β(SE): 0.36 (0.13) cm, p = 0.006). Maternal SF concentrations were associated with greater birth length (β(SE): 0.44 (0.20) cm, p < 0.03). Findings were similar after adjusting SF concentrations for inflammation. IDA was associated with higher risk of low birth weight (RR: 1.99 (1.08-3.68); p = 0.03) and preterm birth (RR: 3.46 (1.81-6.61); p = 0.0002); and lower birth weight (p = 0.02), gestational age at birth (p = 0.0002), and infant WAZ scores (p = 0.02).

CONCLUSIONS

The prevalence of anaemia and iron deficiency was high early in pregnancy and associated with increased risk of adverse pregnancy and infant outcomes. A comprehensive approach to prevent anaemia is needed in women of reproductive age, to enhance haematological status and improve maternal and child health outcomes.